Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.
Findings include:
1. Document review on December 19, 2023, at 9:30 a.m., revealed the September 5, 2023, sprinkler inspection report listed the following deficiency, evidence of corrective action was not available at time of survey:
a. Low air switch found not connected to FACP at time of inspection.
Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the sprinkler system deficiency.
2. Observation on December 19, 2023, at 11:05 a.m., revealed, the first sprinkler room by room 19, lacked a sprinkler wrench.
Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the missing sprinkler wrench.
| | Plan of Correction - To be completed: 03/15/2024
Facility brought this issue to sprinkler vendor, Tilley's Fire Solutions attention. In October 2023, pressure switch was tied into Siemens fire alarm system by onsite electrician and tested. All other dry sprinkler systems previously had low air notifications tied into alarm system and were functional as confirmed by vendor and Director of Facilities or designee.
Sprinkler vendor tested system #3 low air switch during quarterly testing on December 29, 2023 and was found to be fully functional.
Director of Facilities or designee, will ensure sprinkler vendor tests low air switch and alarm system integration during ongoing quarterly testing.
Copies of testing reports will be brought to the quarterly QAPI meeting.
New sprinkler wrench was replaced and labeled to prevent wrench from being removed from Sprinkler Room.
All sprinkler rooms were audited to ensure wrenches were available in each sprinkler room.
Copies of the audit will be brought to the quarterly QAPI meeting.
Director of Facilities or designee, will audit sprinkler rooms annually to ensure wrench is available in each sprinkler room.
Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
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